Provider Demographics
NPI:1003949694
Name:GLENPOOL FAMILY CLINIC A PROF CORP
Entity Type:Organization
Organization Name:GLENPOOL FAMILY CLINIC A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-322-9510
Mailing Address - Street 1:14226 SO ELM
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-1029
Mailing Address - Country:US
Mailing Address - Phone:918-322-9510
Mailing Address - Fax:918-322-9753
Practice Address - Street 1:14226 SO ELM
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-3525
Practice Address - Country:US
Practice Address - Phone:918-322-9510
Practice Address - Fax:918-322-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1000004050AMedicaid
OKE09721Medicare UPIN
OK045380466Medicare ID - Type Unspecified